What is the Heart of New Ulm
(HONU) project
• HONU is a demonstration project
• designed to apply and establish evidence-informed
health improvement practices
• based on the community’s own level of risk and
customized to their preferences.
• It is primarily a systems-level intervention designed to
synchronize and bolster heart health improvement
efforts/resources across key areas within New Ulm,
MN
General Idea of the
Demonstration Project
„ Focus efforts in one zip code
to improve risk factors for heart
attacks.
„ Evaluate outcomes using
existing surveillance tools
where possible.
„ Intervention plan designed and
administered in a flexible,
evolving way.
„ based on community demands
and observed changes in risk
factors over time.
„ Adjusts intervention plan to
using current technologies,
more direct connection to the
healthcare system, and
emphasis on social marketing
to get the masses exposed to
health improvement programs.
Funding and Logistics
• To date, the Allina Center for Healthcare Innovation has invested
$3 million in the HONU project and will continue to invest several
million dollars over the coming years.
• Looking to match those funds via philanthropic grants from federal
agencies, private industry, health plans, foundations, and
individuals to extend the project to 10 years, possibly beyond.
• Project is implemented by the Minneapolis Heart Institute
Foundation, working in close partnership with Allina, the New Ulm
Medical Center, Minneapolis Heart Institute, and various
stakeholder groups in New Ulm.
Why New Ulm?
„ Geographically contained area
„ About 90% of residents are patients
at NUMC
„ Use of the EMR
St. Paul
New Ulm
New Ulm is about
100 miles away
from St. Paul
Why New Ulm
Continued…
„ The community is willing to change
„ The community has established
partnerships:
‟ NUMC working with employers and Park & Rec
‟ Childhood obesity curriculum in schools (DAAN)
‟ City working to have 100% of neighborhoods
walkable (sidewalks)
‟ Electronic medical record for prevention and
wellness follow-up
Getting to Know the 56073 • Agricultural area of south-
central Minnesota
• “The (statistically) most German town in America” *
• 17,199 residents, 13,594 within the New Ulm city limits
• Average age is 38 and adults account for 76% of the population
• 97% identify themselves as White
• 20% report obtaining a Bachelors degree or higher
• 95% report at least some form of health coverage
• Very stable year-over-year population
Why Heart Attacks?
„ The mortality rate from MI’s has dropped considerably over 50 years, but the
attack rate of MI’s has not dropped as much during that timeframe and is
projected to possibly rise in some subgroups due to obesity and diabetes
(e.g., young males, elderly females).
„ The result is that the prevalence of heart disease may also soon rise, along
with its associated healthcare costs. Therefore there is a need to restructure
the manner in which the healthcare system and communities partner so that
more heart attack “cases” can be prevented upfront (versus treated after the
fact).
Basic Rationale The mortality rate from MI’s has
dropped considerably over 50 years,
but the attack rate of MI’s has not
dropped as much during that
timeframe and is projected to
possibly rise in some subgroups due
to obesity and diabetes (e.g., young
males, elderly females).
The result is that the prevalence of
heart disease may also soon rise,
along with its associated healthcare
costs. Therefore there is a need to
restructure the manner in which the
healthcare system and communities
partner so that more heart attack
“cases” can be prevented upfront
(versus treated after the fact).
Primary Objectives
Long-term: To reduce the (age- and sex-adjusted) attack rate of hospitalized acute MI’s among 56073 zip code residents (age 30-79 years) over 10 years.
Primary Objectives
Shorter-term: Improve the proportion of 56073 zip code
residents (age 30-79 years with an active Allina electronic health record) with controlled modifiable risk factors for incident MI’s over 5 years. ‟ Elevated blood lipids (i.e., total chol, LDL chol, HDL
chol, triglycerides)
‟ High blood pressure
‟ Uncontrolled glucose (i.e., type 2 diabetes and pre-diabetes)
‟ Obesity
‟ Tobacco use
‟ Physical inactivity
‟ Low fruit/vegetable consumption
‟ Uncontrolled stress
‟ Medication (i.e., anti-platelet, anti-dyslipidemia, anti-hypertension,anti diabetes) underutilization/non-adherence
Community Penetration
• Screened 5,198 individuals (82% from
the 56073 zip code)
• Enrolled 3,400 individuals in the Move
to Improve community challenge
program
• Over 800 individuals attended at least
one community health education
seminar, worksite lunch-n-learn lecture,
or women’s walking club event
• Engaged 62 employers or civic
organizations in a screening and/or
wellness planning activities
Community Challenge
Move to Improve
Free eight-week challenge to help New Ulm community
members get out, get active and help reduce their risk for
heart attacks.
Participants were given a booklet and a “passport” to help
track their minutes of activity each week. The overall goal
was to get participants moving for at least 150 minutes
through physical activity each week.
Community Challenge Findings
„77% of participants who returned their passports felt they were
confident that they would accumulate at least 150 minutes of
physical activity each week.
„During the first week 94% of participants accumulated 150
minutes or more of physical activity!
„Throughout the entire eight week program, 90% or more
participants accumulated at least 150 minutes of physical
activity.
• Obesity is particularly problematic in New Ulm, along with some medical risks, particularly high LDL.
• This is supported by observations of low fruit/vegetable consumption, a high proportion of participants with metabolic syndrome, and significant underutilization of preventive medical therapies (e.g., aspirin, statin, blood pressure medications).
• Intervention efforts should most heavily focus on improving the food environment (as it relates to obesity) and medical management of those at high cardiometabolic risk.
“Community Diagnosis” (from screening)
How to Impact the
Community „ Healthcare
„ Community
‟ Special events
‟ Community challenge
‟ Grocery stores and restaurants
„ Worksites
‟ Health promotion
‟ Policy change
HONU spreads awareness regarding heart health through
many programs year round.
•Go Red for Women
•Jingle Bell Jam
•Community Challenge
•Community Leaders Event
Community Leaders
Event with Bob Harper
Bob Harper, Health and Motivational Expert from NBC’s the Biggest
Loser, spoke during the Heart of New Ulm Summit in 2009 at the
District 88 Administrative Center Auditorium in New Ulm.
Go Red for Women Event
The Go Red for Women event has brought
hundreds of women together over the past two
years to celebrate Heart Health Month.
Participants enjoy a heart healthy meal, listened
to inspiring presentations and learn about the
HONU project all while wearing Red!
Go Red for Women
Workout with Chris Freytag
Freytag is a self proclaimed fitness addict from Minneapolis. She has been in
the health and fitness industry for over 20 years. Chris lead a group of New Ulm
residents in a Go Red for Women workout at the New Ulm recreation center
prior to the evening event.
Jingle Bell Jam On December 12, 2009, the Jingle Bell Jam
walk/run attracted over 600 joyful participants!
Community Challenge
2010 • 18 month challenge.
• Divide New Ulm into districts.
• Each district has leaders designed
to promote healthy behaviors.
• Quarterly changes in focus
• Creating Ripple Effect—sustainable
change
Food Works
„ Grocery store tours
„ NEMS (nutrition environment
measures surveys)
„ Restaurant and grocery tours
„ Cooking presentations
What’s Cooking New Ulm?
„ Cable access cooking show with
guest cooks from the community.
„ Project update and Fit in 5 segment
is included in each 30 minute
episode.
„ A different show each week.
In the Worksites
„ Work with worksites to help
implement health promotion
programs.
„ Help worksites implement policy
change. ie healthy food and/or
tobacco policies.
Implementation Process
„ Screenings done at worksites.
„ Aggregate data collected and
shared with committee.
„ Suggestions are made for
programming.
„ Programming options are provided.
Behavior Change Program
Holiday Trimmings
Eight-week incentive program designed to help employees prevent
weight gain during the holiday season.
The program started one to 10 days prior to the Thanksgiving
holiday (November 16 to November 25) and ended in January
(January 4 to January 15).
Holiday Trimmings Results
Holiday Trimmings 2009
Report
Total
How many total participants
submitted weight online or at
weigh in?
255
How many Locations 13
Average pre-program weight 177.08 lbs
Average post-program weight 173.20 lbs
Normal Weight
30%
Overweight 35%
Obese 35%
Pre- Program BMI Distribution Among Holiday Trimmings Participants
Normal Weight
39%
Overweight 29%
Obese 32%
Post-Program BMI Distribution Among Holiday Trimmings Participants
Policy Change
„ Smoking Cessation
„ Healthy food policy
„ Alternative work schedules
„ Ergonomic evaluation
Stakeholders
•NUMC
•Brown County Health Department
• City Council
• Festival Organizers
• Fitness Centers
• Parks & Recreation
• Schools
• Worksites: Windings, Kraft, 3M, Associated Milk
Producers Inc, August Schell Brewery
Project Partners „ NU Park and Recreation
„ Fitness facilities like Anytime Fitness and SNAP
„ Chamber of Commerce
„ NUCAT
„ Brown County Health (SHIP)
„ Service groups like Sertoma, Optomist Club,
Rotary
„ Grocery stores
„ Restaurants
Park and Recreation
Partnership „ Provide screening site.
„ Support on steering committee.
„ Promotion of programs.
Results So Far -
Community „ 94 percent are aware of HONU.
„ Increase in fruits and veggies 17
percent to 22 percent.
„ 94 percent are confident HONU will
succeed.
Results So Far-Worksite
„ Windings
‟ WOHS (Windings Optimal Health
Score)
‟ Physical activity increased to 140 mins
‟ Fruit and vegetable consumption up 1
point
‟ Productivity up 10 percent
‟ Average total cholesterol down 10
points
In Summary
„ HONU is designed to help improve
the health of an entire community.
„ The goal is the prevention of early
age MI.
„ Being able to replicate the project
will provide a template for
prevention in other communities.
The Goal of Partnerships
„ The project will only succeed with
community and worksite input.
„ Partnerships are vital to the
sustainability of the project
programs and impact.
„ Partnerships with community are
important for replication in other
communities.
Early Keys to Success (i.e.,
take-away’s) 1. Use your own data
2. Align your community’s existing
resources
3. Extend the primary care relationship
4. Push for support from those who benefit
Heart Disease
„ Definition: Broad term to describe several
types of cardiovascular disease
„ 1. CAD (coronary artery disease)
„ 2. CHF (congestive heart failure)
„ 3. Heart Arrhythmia
„ 4. Cardiomyopathy
What is CAD?
„ Major form of Cardiovascular Disease
„ Occurs when arteries are narrowed by
fatty deposits leading to plague build up
„ Blood supply is restricted to heart muscle
thereby causing a heart attack
Heart Disease Statistics
„ Every 34 seconds a person in the United States dies from heart
disease.
„ More than 2,500 Americans die from heart disease each day.
„ Every 20 seconds, a person in the United States has a heart attack.
„ At least 250,000 people die of heart attacks each year before they
reach a hospital.
„ Studies show that under-educated people are more likely to suffer
heart attacks.
„ Almost 6 million hospitalizations each year (in the United States) are
due to cardiovascular disease.
„ Since 1900, Cardio Vascular Disease has been the number 1 killer
in the United States for every year but 1918.
„ Men suffer heart attacks about 10 years earlier in life than women
do.
Causes of Death in US „ Number of deaths for leading causes of death
„ Heart disease: 616,067
„ Cancer: 562,875
„ Stroke (cerebrovascular diseases): 135,952
„ Chronic lower respiratory diseases: 127,924
„ Accidents (unintentional injuries): 123,706
„ Alzheimer's disease: 74,632
„ Diabetes: 71,382
„ Influenza and Pneumonia: 52,717
„ Nephritis, nephrotic syndrome, and nephrosis: 46,448
„ Septicemia: 34,828
„ Source: Deaths: Final Data for 2007, table B
Contributing Factors for Heart
Disease „ Tobacco Use
„ Obesity
„ Inactivity
„ Diabetes/Prediabetes
„ Hypertension
„ Metabolic Syndrome
Smoking(Per US Surgeon General-”the leading
preventable cause of disease and deaths in the US”)
„ Contributor of Heart Disease that is MOST Preventable
„ Increases risk 2-4 times of developing CAD
„ Increase Risk of sudden cardiac death
„ In the United States, an estimated 24.8 million men (23.1 percent) and 21.1 million women (18.3 percent) are smokers. These people are at higher risk of heart attack and stroke. The latest estimates for persons age 18 and older show...*
„ Among whites, 23.5 percent of men and 20.6 percent of women smoke (2008).
„ Among blacks, 25.6 percent of men and 17.8 percent of women smoke.
„ Among Hispanics, 20.7 percent of men and 10.7 percent of women smoke.
„ 9.9 percent of Asian adults smoke.
„ 24.3 percent of American Indian/Alaska Native adults smoke.
„ * National Health Interview Survey (NHIS), 2008, National Center for Health Statistics
How does smoking affect CAD
„ Increases BP
„ Decreases exercise tolerance
„ Increases tendency for blood to clot
„ Decreases HDL
Obesity
„ The Heart has to work harder in people who are overweight, putting more stress on the heart
„ Also, obese tend to have higher LDL, increase BP, and increased risk for diabetes
• Obesity by Race/Ethnicity 2006-2008
• New Obesity Data Shows Blacks Have the Highest Rates of Obesity
• Blacks had 51 percent higher prevalence of obesity, and Hispanics had 21 percent higher obesity prevalence compared with whites.
• Greater prevalences of obesity for blacks and whites were found in the South and Midwest than in the West and Northeast. Hispanics in the Northeast had lower obesity prevalence than Hispanics in the Midwest, South or West.
• For this study analysis, CDC analyzed the 2006−2008 BRFSS data.
BMI
„ Weight in pounds divided by 2.2
„ Then, multiply height in inches by 0.254
„ Normal: BMI 18.5-24.9
„ Overweight: BMI 25-30
„ Obese: BMI greater than 30
„ Morbid obesity: BMI greater than 40
1999
Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2009
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2009
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Cost of Obesity
„ Obesity-a contributing factor in 100000-
400000 deaths per year
„ 117 Billion dollars in direct cost and
indirect cost
Lack of Physical Activity/Exercise
„ Contributes to weight gain
„ Activity Benefits the heart
„ -activity Helps lower cholesterol and blood
pressure
„ Goal is 30 minutes 5 times per week
Benefits of exercise
„ Improves circulation and help your body use oxygen better.
„ Strengthens Heart muscle
„ Improved energy -allows you to do activities without becoming tired or short of breath.
„ Improved endurance.
„ Lowers blood pressure.
„ Improves muscle tone, strength, flexability and balance.
„ Help bones be stronger
„ Prevent weight gain, helps with weight loss
„ Exercise is helpful in reducing stress, tension
„ Improved self esteem and self image.
„ Improved sleep, rest and relaxation
Your target heart rate isn't one rate but a
range of rates (beats per minute, or bpm),
expressed as percentages of your maximum
heart rate, that are safe for you to reach
during exercise. For most healthy people, the
American Heart Association recommends an
exercise target heart rate ranging from 50% to
75% of your maximum heart rate, which is
normally calculated as the number 220 minus
your age.
Hypertension
„ Often called the “Silent Killer”
„ Normal is considered less than 120/80.
„ High Blood pressure is 140/80
„ High risk population goal is 130/85
„ Blood pressure (BP) is the pressure
exerted by circulating blood upon the
walls of blood vessels
How to control Blood pressure?
• Weight management
• Exercise
• Salt restriction
• Don’t Smoke
• Limit Alcohol
• Stress Management
Incidence of HTN
• 36% of African Americans
• 20% of Caucasians, Hispanics and
Native Americans
• Asians have lowest incidence < 10%
• African Americans have earlier onset
and more severe consequences of HTN
Age-adjusted total prevalence of diabetes in
people aged 20 years or older, by
race/ethnicity—United States, 2002
Health Interview Survey and 1999-2000 National Health and Nutrition Examination Survey estimates projected to year 2002. 2002 outpatient database of the Indian Health Service.
Incidence of DM(2007)
• Total 23.6 million people have diabetes
• 17.9 million diagnosed
• 5.7 million undiagnosed
Metabolic Syndrome
• Triglycerides > 150
• HDL <40 for men, < 50 for women
• Blood pressure > 130/85
• Fasting glucose >100
• Abd. Circumference > 40 males, >35
women
Step 1
LDL Cholesterol-Primary Target of Therapy
< 100-optimal
100-129-Near Optimal/above optimal
130-159-Borderline High
160-189-High
> 190- Very High
Total Cholesterol
< 200-Desirable
200-239 Borderline High
> 140-High
HDL Cholesterol
< 40- Low
> 60- High
(National Institutes of Health)
Step 2
• Identify presence of clinical atherosclerotic disease that confers high risk for Coronary Heart disease (CHD ) events
* Clinical CHD
* Symptomatic carotid artery disease
* Peripheral Arterial disease
* Abdominal Aortic aneurysm
* Diabetes (National Institutes of Health)
Step 3
• Determine presence of Major risk factors
(other than LDL) that modify LDL goals
* Smoking
* HTN BP >140/90 or on TX
* Low HDL (<40)
* Fam HX of premature CHD (1st degree male
relative < 55y/o; Female < 65 y/o
*Age (men > 45; women > 55)
Step 4
• If 2+ risk factors (other than LDL are
present without CHD or CHD risk
equivalent, assess 10 year CHD risk
(Framingham tables)
* > 20%-CHD risk equivalent
* 10-20%
* 10 %
Step 5
• Establish LDL goal of therapy
• Determine need for TLC (therapeutic
lifestyle changes
• Determine Level for drug considerations
Treatment Guidelines
• CHD or CHD risk Equivalents (10 yr risk
> 20%)
*LDL Goal less than 100
-Consider TLC if LDL > 100
-Drug Therapy > 130, drug therapy
optional if LDL 100-129
Treatment Guidelines Cont.
• 2+ Risk Factors (10 year risk <20 %)
* LDL Goal < 130
- TLC if LDL > 130
- Drug Therapy:
if 10 yr risk 10-20% >130
if 10 yr risk < 10% and LDL > 160
Treatment Guidelines Cont.
• 0-1 risk factor
* LDL Goal < 160
- TLC if LDL > 160
- Consider Drug Therapy if:
LDL > 190
LDL 160-189-Drug Therapy Optional
TLC (Therapeutic Lifestyle
Changes)
• Diet:
* Saturated fat < 7% of calories,
cholesterol < 200mg/day
* Fiber 10-25 mg/day
* Plant Stanols and sterols (2grams/d)
Weight Management
Increased Physical Activity
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